Jane Dotson
Medicare is a public health insurance program that covers most of the costs for approved health care services and supplies. It is possible to have both Medicare and private insurance at the same time, and this can happen if you have coverage through an employer, your spouse's employer, COBRA, or TRICARE. If you have both types of insurance, a process called coordination of benefits determines which insurance provider pays first, and this provider is called the primary payer. The primary payer pays for any covered services until the coverage limit has been reached, after which the secondary payer covers the costs that the primary payer doesn't cover. Medicare health plans bundle your Part A, Part B, and usually Part D coverage into one plan, and you must have both Part A and Part B to join a Medicare Advantage Plan.
| Characteristics | Values |
|---|---|
| Medicare and other insurance | It is possible to have both Medicare and other insurance at the same time. |
| Medicare as primary insurance | If you have other insurance, Medicare is generally considered to be the primary insurance. |
| Coordination of benefits | When you have both Medicare and other insurance, a process called "coordination of benefits" determines which insurance provider pays first. |
| Primary and secondary payers | The "primary payer" pays up to the limits of its coverage, then sends the remaining balance to the "secondary payer." |
| Medicare Supplement Insurance (Medigap) | You can buy Medicare Supplement Insurance (Medigap) from a private company to help pay your share of costs in Original Medicare. |
| Medicare Advantage | Medicare Advantage Plans are offered by private, Medicare-approved insurance companies and provide an alternative way to receive your Original Medicare Part A and Part B benefits. |
| Drug coverage | You can join a separate Medicare drug plan (Part D) to get drug coverage. |
| Coverage options | If you have Medicare and other insurance, your coverage options may include employer or union coverage, military benefits, or veterans' benefits. |
| Eligibility and enrollment | It is important to check your eligibility and compare the benefits and costs of Medicare and other insurance plans before enrolling. |
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What You'll Learn
- Medicare and private insurance can be combined under certain circumstances
- Medicare and other insurance: determining the primary and secondary payer
- Medicare Advantage Plans: what are they and how do they differ from Original Medicare
- Medigap policies: what they cover and who can buy them
- Medicare and insurance coverage for spouses
Medicare and private insurance can be combined under certain circumstances
There are several situations in which you may have private insurance and Medicare at the same time. For example, if you have coverage through your employer, you may still have private insurance when you become eligible for Medicare. Similarly, you can have Medicare and also be covered on a group plan provided by your spouse's employer. COBRA allows you to temporarily keep private insurance coverage after your employment ends. TRICARE provides coverage for active and retired members of the military and their dependents.
Medicare Advantage plans are an alternative way to receive your Original Medicare Part A and Part B benefits through private, Medicare-approved insurance companies. You're still enrolled in Medicare, but the Medicare Advantage plan administers your benefits. The plan sets its premiums, deductible, and coinsurance/copayment amounts. Most Medicare Advantage plans include prescription drug coverage, and many have extra benefits, like routine dental care.
Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private company that helps pay your share of costs in Original Medicare. Generally, you need Part A and Part B to buy a Medigap policy. Some Medigap policies offer coverage when you travel outside the US. Generally, Medigap policies don't cover long-term care, vision, dental, hearing aids, private-duty nursing, or prescription drugs.
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Medicare and other insurance: determining the primary and secondary payer
Medicare beneficiaries may have other insurance coverage, such as a group health plan, retiree coverage, or private insurance. When an individual has Medicare and another insurance plan, a process called "coordination of benefits" determines which insurance provider pays first. This provider is known as the "primary payer". The primary payer pays for any covered services up to the limits of its coverage. If there are any remaining costs, the "secondary payer" will cover those expenses. However, the secondary payer may not cover all of the remaining costs, in which case the individual may be responsible for the remaining balance.
There are several situations in which Medicare and other insurance coverage may interact, and the determination of the primary and secondary payer depends on the specific circumstances. Here are some common scenarios:
- Working Aged (Medicare beneficiaries age 65 or older) with an Employer Group Health Plan (GHP): If the individual is 65 or older and covered by a GHP through their own or their spouse's current employment, the number of employees in the company determines the primary payer. If the employer has less than 20 employees, Medicare pays primary, and the GHP pays secondary. If the employer has 20 or more employees, the GHP pays primary, and Medicare pays secondary.
- Retirement Plan: If an individual is 65 or older and has an employer retirement plan, Medicare typically pays primary, and the retiree coverage pays secondary.
- No-Fault or Liability Insurance: In situations where no-fault or liability insurance is involved, such as an accident, the no-fault or liability insurance pays primary for accident-related healthcare services, and Medicare pays secondary.
- Workers' Compensation: If an individual is entitled to Medicare and has a job-related illness or injury covered under Workers' Compensation, Workers' Compensation pays primary for healthcare items or services related to those claims. Medicare generally does not pay for injuries or illnesses covered by workers' compensation. However, if Workers' Compensation denies a claim, Medicare may make a conditional payment to ensure the beneficiary doesn't have to pay out of pocket, but this amount must be repaid to Medicare if a settlement or award is made.
- TRICARE: TRICARE provides coverage for active and retired military members and their dependents. If an individual is on active duty, TRICARE pays first for Medicare-covered services, and Medicare pays second. If the individual is not on active duty, Medicare pays first, and TRICARE may pay second.
It is important to note that having multiple insurance coverages does not always provide an advantage. While it can offer additional benefits and coverage, coordinating benefits between Medicare and other insurance plans can be a complicated process. Individuals with Medicare and other insurance coverage should inform their doctors and healthcare providers about their insurance situation to ensure proper billing and avoid delays.
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Medicare Advantage Plans: what are they and how do they differ from Original Medicare?
Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare and is offered by private health insurance companies. It covers everything that Original Medicare (Part A and Part B) covers and often includes extra benefits, such as prescription drug coverage, routine dental care, routine vision care, and routine hearing care.
Original Medicare is administered by the federal government and covers inpatient hospital care, nursing facility care, nursing home care, hospice care, home healthcare, certain doctors' services, outpatient care, medical supplies, and preventive services. It does not include prescription drug coverage, so you would need to purchase a separate plan and pay a separate premium.
Medicare Advantage plans can be a good option for those seeking expanded coverage beyond what Original Medicare offers. These plans often include Part D prescription drug coverage, whereas Original Medicare does not. However, with Original Medicare, you have the freedom to see any doctor or hospital that accepts Medicare anywhere in the US, while Medicare Advantage plans typically require you to use doctors within the plan's network.
It is possible to have both private insurance and Medicare at the same time. In such cases, a process called coordination of benefits determines which insurance provider pays first. This provider is called the primary payer, and they pay up to the limits of their coverage. The remaining balance is then sent to the "secondary payer", who may or may not cover the remaining costs.
Overall, Medicare Advantage plans provide an alternative to Original Medicare, offering expanded coverage and benefits through private insurance companies.
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Medigap policies: what they cover and who can buy them
Medicare is a public health insurance plan that is government-funded. It is possible to have both private insurance and Medicare at the same time. When you have both, a process called "coordination of benefits" determines which insurance provider pays first. This provider is called the "primary payer". The primary payer pays for any covered services until the coverage limit has been reached. Then, the "secondary payer" pays for the costs that the primary payer doesn't cover.
Medigap, or Medicare Supplement Insurance, is extra insurance you can buy from a private company that helps pay your share of costs in Original Medicare. Medigap policies are standardized, and in most states, they are named by letters, like Plan G or Plan K. The benefits in each lettered plan are the same, no matter which insurance company sells it. The price is the only difference between policies with the same letter sold by different companies. Generally, you need Part A and Part B to buy a Medigap policy.
Medigap plans generally help cover your share of costs for services that are covered by Original Medicare (Part A and Part B). The benefits are different in each plan – you can buy the one that meets your needs. Medigap policies help cover out-of-pocket costs associated with Original Medicare, like emergency medical care when you travel outside the US (foreign travel emergency care). Some Medigap policies also cover other extra benefits that aren't covered by Medicare, like certain vision, hearing, and dental services. However, Medigap plans generally do not cover long-term care, vision, dental, hearing aids, private-duty nursing, or prescription drugs.
The ideal time to buy a Medigap policy is when you're 65 or older and first enrolled in both Medicare Part A and Part B. During this six-month window, called your Medigap Open Enrollment Period, you can buy any Medigap policy available in your state, even if you have pre-existing health conditions. In most cases, you cannot change your Medigap coverage outside your Medigap Open Enrollment Period.
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Medicare and insurance coverage for spouses
Medicare is an individual insurance plan, meaning it does not extend to spouses or dependents. However, there are certain circumstances where a spouse can be covered under Medicare.
If you are eligible for Medicare benefits and your spouse is younger, there are several options to ensure they are covered. If your spouse is left without coverage when you leave your group health insurance, you can look into a COBRA policy for them if your employer's health insurer offers one. Otherwise, you may have to insure your spouse through other private health insurance companies. Alternatively, your spouse may continue coverage through your employer plan if you keep working and retain the employer coverage. If your spouse is younger than 65 and receives disability benefits from Social Security for 24 months, they automatically become eligible for Medicare on the 25th month. If your spouse is older than you and not working when they turn 65, they may be eligible for Medicare benefits based on your work record, even if you are not retired or receiving Medicare coverage yourself.
If you have both Medicare and private insurance, a process called "coordination of benefits" determines which insurance provider pays first. This provider is called the "primary payer" and pays for any covered services until the coverage limit has been reached. The "secondary payer" pays for costs that the primary payer doesn't cover. However, the secondary payer may not cover all costs, and you may be responsible for the remaining balance.
If you are planning on enrolling in a Part D prescription drug plan and you and your spouse are different ages, you must enrol during each of your individual initial enrolment periods. You may avoid a premium penalty if you have comparable coverage through your employee insurance.
In the United States, once you turn 65, you are eligible for Medicare benefits if you are a citizen or have been a legal resident for five years or more and have worked for at least 40 quarters (10 years), paying federal taxes. You may also be eligible for Medicare coverage if you are younger than 65 but have a qualifying disability or end-stage renal disease.
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Frequently asked questions
Yes, in certain instances, private health insurance and Medicare can be combined. This can happen if you have coverage through an employer, coverage under your spouse's private health insurance, COBRA, or TRICARE.
When you have both, a process called "coordination of benefits" determines which insurance provider pays first. This provider is called the "primary payer" and pays up to the limits of its coverage. The other provider, called the "secondary payer", then pays for costs that the primary payer doesn't cover.
Having both Medicare and private insurance can help cover costs that Medicare alone may not. For example, Medicare Supplement Insurance (Medigap) is extra insurance that helps pay your share of costs in Original Medicare. Additionally, Medicare Advantage Plans may offer some extra benefits that Original Medicare doesn’t cover, such as vision, hearing, and dental services.
